Description

Meningitis is one of the infectious disorders of the nervous system.

Meningitis is an inflammation of the lining around the brain and spinal cord
caused by bacteria or viruses.

Bacterial meningitis is caused by bacteria.

Meningitis can be the primary reason a patient is hospitalized or can develop

during hospitalization.

Pathophysiology
Meningeal infections generally originate in one of two ways: through the bloodstream or by
direct spread.

Brain surrounded by pus (the yellow-greyish coat around the

brain, under the dura lifted by the forceps), the result of bacterial meningitis. A brain autopsy
demonstrating signs of meningitis. The forceps (center) are retracting the dura mater (white).
Underneath the dura mater are the leptomeninges, which appear to be edematous and have
multiple small hemorrhagic foci(red).
Transmission. N. meningitidis concentrates in the nasopharynx and is
transmitted by secretion or aerosol contamination.

Entry. One of the causative organism enters the bloodstream, it crosses the
blood brain barrier and proliferates in the cerebrospinal fluid.

Stimulation. The host immune system stimulates the release of cell wall
fragments and lipopolysaccharides, facilitating inflammation of the subarachnoid
and pia mater.

Increased ICP. Because the cranial vault contains little room for expansion, the
inflammation may cause increased intracranial pressure.

Circulation. CSF circulates through the subarachnoid space, where inflammatory

cellular materials from the affected meningeal tissue enter and accumulate.

Causes
Factors that may cause bacterial meningitis include:

Tobacco use. Tobacco use predisposes the patient to meningitis.

Viral upper respiratory infection. Viral upper respiratory infection increase the
amount of droplet production.

Otitis media. Otitis media increase the risk of bacterial meningitis because the
bacteria can cross the epithelial membrane and enter the subarachnoid space.

Immune system deficiency. People with immune system deficiencies are also at
greater risk for development of bacterial meningitis.

Bacteria. The bacteria Streptococcus pneumoniae and Neisseria

meningitides are responsible for 80% of cases of meningitis in adults, as well as
Haemophilus influenzae in children.

Clinical Manifestations
Headache and fever are frequently the initial symptoms.

Brudzinskis sign and Kernigs sign

Headache. The headache is usually steady or throbbing and very severe as a
result of meningeal irritation.

Neck mobility. A stiff and painful neck can be an early sign and any attempts at
flexion of the head are difficult.

Positive Kernigs sign. When the patient is lying with the thigh flexed on the
abdomen, the leg cannot be completely extended.

Positive Brudzinskis sign. When the patients neck is flexed, flexion of the
knees and hips is produced; when the lower extremity of one side is passively
flexed, a similar movement is seen in the opposite extremity.

Photophobia. Extreme sensitivity to light is a common finding.

Skin lesions. Skin lesions develop, ranging from a petechial rash with purpuric
lesions to large areas of ecchymosis.

Cognitive impairment. Disorientation and memory impairment are common

early in the course of the illness.

Seizures. Seizures can occur and are the result of areas of irritability in the brain.

Prevention
The prevention of bacterial meningitis includes:

Vaccine. The Advisory Committee on Immunization Practices of the Centers for

Disease Control and Prevention (CDC) recommends that the meningococcal
conjugated vaccine be given to adolescents entering high school and to college
freshmen living in dormitories.

Health education. Most states mandate education addressing meningococcal

meningitis.

Antimicrobial prophylaxis. People in close contact with patients with

meningococcal meningitis should be treated with antimicrobial chemoprophylaxis
using rifampin, ciprofloxacin, or ceftriaxone sodium.

Complications
Complications of patients with bacterial meningitis include:

Visual impairment. Infection may spread towards the eyes if left untreated.

Deafness. Deafness may also occur when the bacteria reaches the optic nerve.

Seizures. The bacteria irritates the meningeal layers and may lead to seizures.

Assessment and Diagnostic Findings

If the clinical presentation suggests meningitis, diagnostic testing is conducted to identify

causative organism.

Computed tomography (CT) scan or magnetic resonance imaging (MRI)

scan to detect a shift in brain contents (which may lead to herniation) prior to a
lumbar puncture.

Key diagnostic tests: bacterial culture and Gram staining of CSF and blood.

Diagnosis is made by lumbar puncture. The CSF is cloudy. Gram stain of the
CSF reveals organisms in 70% to 80% of all cases. When the organisms cannot
be identified, bacterial antigens can be determined. H. influenzae is frequently
detected with this technique. Clients with bacterial meningitis demonstrate the
following:
o Moderately elevated CSF pressures
o Elevated CSF protein level (normal, 15 to 45 mg/dl)
o Decreased CSF glucose level (normal, 60 to 80 mg/dl, or two thirds of
the serum glucose value)
o Elevated white blood cell count, usually increased (100 to 10,
000/cm3), with predominantly polymorphonuclear leukocytes.

Medical diagnosis is made by assessment of clinical manifestations and is

confirmed by isolating the causative organism from the CSF.

Medical Management
Bacterial meningitis constitutes a medical emergency. Prognosis varies according to the
causative organism. The use of antibiotics has reduced the death rate to less than 5% for all
types of bacterial meningitis. If untreated, it can be fatal within hours to days. Deaths most
often occur in newborn infants and in older adults. Complications are rate but may
include septic shock, vasomotor collapse, seizures, and increased ICP attributable to
hydrocephalus, brain swelling, and fluid overload. Residual neurologic deficits are rare in
adults.
A unique problem in treating CNS infection is that [highlight]an intact blood-brain barrier
prevents complete penetration of the antibiotic[/highlight]. However, inflammation inhibits the
blood-brain barrier, so for short time antibiotics penetrate the CNS. Antibiotics are given

intravenously; the blood-brain barrier recovers as inflammation subsides, and high doses
are required to reach the CSF.

Adequate fluid and electrolyte balance must be maintained. Frequent assessment

of the neurologic status is indicated to detect early manifestations of increasing
ICP and seizures. Anticonvulsants may be prescribed for seizure prevention.

Antibiotic therapy. Early administration of an antibiotic that crosses the blood

brain barrier into the subarachnoid space in sufficient concentration to halt the
multiplication of bacteria like Vancomycin administered intravenously.

Corticosteroids. Dexamethasone has been shown to be beneficial as adjunct

therapy in the treatment of bacterial meningitis if it is administered 15 to 20
minutes before the first dose of antibiotic and every 6 hours for the next 4 days.

Fluid volume expanders. Dehydration and shock are treated with fluid volume
expanders.

Nursing Management
The patient with meningitis is critically ill; therefore many of the nursing interventions are
collaborative with the physician, respiratory therapist, and other members of the healthcare
team.

Nursing Assessment
Assessment of the patient with bacterial meningitis include.

Neurologic status. Neurologic status and vital signs are continually assessed.

Pulse oximetry and arterial blood gas values. These values are used to
quickly identify the need for respiratory support.

Nursing Diagnosis
Based on the assessment data, major nursing diagnoses include:

Risk for Infection Transmission related to contagious nature of organism

Acute Pain related to headache, fever, neck pain secondary to meningeal irritaiton

Acute Pain related to nuchal rigidity, muscle aches, immobility and increased
sensitivity to external stimuli secondary to infectious process

Impaired Physical Mobility related to intravenous infusion, nuchal rigidity and

restraining devices

Activity Intolerance related to fatigue and malaise secondary to infection

Risk for Impaired Skin Integrity related to immobility, dehydration, and diaphoresis

Risk for Injury related to restlessness and disorientation secondary to meningeal

irritation

Interrupted Family Process related to critical nature of situation and uncertain

prognosis

Anxiety related to treatment and risk of death

Risk for Ineffective Therapeutic Regimen Management

Nursing Care Planning & Goals

Goals for a patient with bacterial meningitis include:

Protection against injury.

Prevention of infection.

Restoring normal cognitive functions.

Prevention of complications.

Nursing Interventions
Important components of nursing care include the following measures:

Assess neurologic status and vital signs constantly. Determine oxygenation

from arterial blood gas values and pulse oximetry.

Insert cuffed endotracheal tube (or tracheostomy), and position patient on

mechanical ventilation as prescribed.

Assess blood pressure (usually monitored using an arterial line) for incipient
shock, which precedes cardiac or respiratory failure.

Rapid IV fluid replacement may be prescribed, but take care not to overhydrate
patient because of risk of cerebral edema.

Reduce high fever to decrease load on heart and brain from oxygen demands.

Protect the patient from injury secondary to seizure activity or altered level of
consciousness (LOC).

Monitor daily body weight; serum electrolytes; and urine volume, specific
gravity, and osmolality, especially if syndrome of inappropriate antidiuretic
hormone (SIADH) is suspected.

Prevent complications associated with immobility, such as pressure

ulcers and pneumonia.

Institute infection control precautions until 24 hours after initiation of antibiotic

therapy (oral and nasal discharge is considered infectious).

Inform family about patients condition and permit family to see patient at
appropriate intervals.

Evaluation
Expected patient outcomes include:

Avoidance of injury.

Avoidance of infection.

Restoration of normal cognitive functions.

Prevention of complications.

Discharge and Home Care Guidelines

After hospitalization, the patient at home should:

Activities. Alternate rest and activity to conserve energy.

Diet. Consume safe, clean, and healthy foods.

Asepsis. Promote simple infection control procedures at home.

Infectious process. Identify signs and symptoms of an infectious process and

report to the physician promptly.

Documentation Guidelines
The focus of documentation in patients with bacterial meningitis are:

Clients description of response to pain.

Acceptable level of pain.

Prior medication use.

Current physical findings.

Clients understanding of individual risks and safety concerns.

Availability and use of resources.

Current and previous level of function.

Effect on independence and lifestyle.

Results of laboratory and diagnostic tests.

Mental status pr cognitive evaluation results.

Plan of care.

Teaching plan.

Response to interventions, teaching, and actions performed.

Attainment or progress towards desired outcomes.

Modifications to plan of car